Provider Demographics
NPI:1336202498
Name:EVANS, TAMMY L
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:L
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:L
Other - Last Name:PRIGANC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5150 FOUNTAINS DR S
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-5715
Mailing Address - Country:US
Mailing Address - Phone:843-455-2415
Mailing Address - Fax:
Practice Address - Street 1:5150 FOUNTAINS DR S
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-5715
Practice Address - Country:US
Practice Address - Phone:843-455-2415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC38412251P0200X
FL379082251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1333Medicaid
FL112495700Medicaid